Disordered eating and sexuality – October 3, 2014

In preparation for some upcoming workshops, I’ve been learning more about barriers to healthy sexual functioning, including age, disability and eating disorders. For this month’s blog, I am focusing on eating disorders and trying to understand the complex physical, emotional and psychological issues involved. The literature is extensive and theories about causation abound; but there is less written about their effects on sexual functioning.

What is food preoccupation, how common is it, when does it become a concern and how does it affect relationships and sexual health?

If considered on a continuum, food and weight preoccupation runs from concern about weight to compulsive dieting to compulsive over-eating to anorexia nervosa and bulimia nervosa. Eating disorders such as anorexia, bulimia and binge eating can persist for years, even an entire lifetime. An estimated 10 per cent of individuals with anorexia nervosa die within 10 years of their first episodes. In 2002, 1.5 per cent of 15 to 24-year-old Canadian women surveyed had an eating disorder.

Weight preoccupation can begin at an early age. Twenty-eight per cent of girls in grade nine and 29 per cent in grade 10 have engaged in weight-loss behaviours. Thirty-seven percent of girls in grade nine and 40 per cent in grade 10 perceived themselves as too fat. Even among students of “normal-weight” (based on BMI), 19 per cent believed that they were too fat, and 12 per cent of students reported attempting to lose weight (see Public Health Agency of Canada information).

How does weight preoccupation affect sexual functioning?

While there is a big gap between a perception that one is “too fat” and a behaviour that is compulsive, it is a truism that media images feed in to girls’ and women’s desire to be thin. In the general population, negative body image can affect self-esteem and the ability to enjoy one’s sexuality. Body image issues that plague many of us are clearly magnified for women with eating disorders. But the physiological effects go much deeper.

A study published in 2010 found that nearly two-thirds of women with eating disorders reported loss of libido and sexual anxiety.

“One consistently observed finding across sexual functioning domains was the association between low lifetime minimum BMI and loss of libido, sexual anxiety and sexual relationships. These findings are consistent with the explanation that low body weight impairs the physiological functioning of sexual organs…”

The researchers conclude that “independent of physical changes, individuals with lower BMIs experience a more severe presentation of the eating disorder” which “may be associated with more profound body dissatisfaction, distortion, depression and discomfort with physical contact, all of which may be associated with loss of libido and elevated sexual anxiety…” In other words, sexual intimacy is a fundamental aspect of healthy relationships that can be disrupted by an eating disorder.

How does dissatisfaction with one’s body and low self-esteem evolve into a full blown compulsion with its associated effects on sexuality?

We understand from the literature that women with eating disorders primarily seek to have control over their bodies. What triggers this loss of control?

A controlling family, a traumatic series of events like sexual trauma and even the arrival of puberty may all contribute to a feeling of lost control.

For someone living in a controlling family, for example, food intake and weight are areas of their life they believe they can bring under their own control. Anorexia may be triggered by this realization. The National Eating Disorder Information Centre (NEDIC) sees control as the “central paradox.”

Faced with high social expectations and a “shaky sense of self,” a woman assumes that she can at least gain approval by being thin. The ideal thin body holds promise. But controlling the body becomes a precarious substitute for real control in her life. “Women feel in control of their lives through controlling their bodies, yet the need to establish this false and precarious control suggests they are desperately out of control.

Another potential trigger is childhood sexual abuse. Mary Anne Cohen suggests women who were sexually abused as children may develop an eating disorder because of guilt, shame or self-punishment. She says sexual abuse survivors may also be trying to de-sexualize themselves—becoming either tiny and childlike or obese. They may try to make their bodies “perfect” and thus “more powerful, invulnerable, and in control, so as not to re-experience the powerlessness they felt as children… Some survivors of sexual abuse are afraid [my emphasis] to lose weight because it will render them feeling smaller and childlike… Binge eating, purging or starving then becomes their ongoing self-induced punishment.”

How does this loss of control and attempt to regain it play out in a relationship aside from the physiological factors described above?

A woman who is preoccupied with her relationship with food, may be less likely to develop the skills that are essential for successful intimate relationships, including maintaining her status in a relationship as well as her ability to negotiate sexual activities and safety. Women who feel powerless; i.e., have lost control, may be less likely to be able to protect themselves from emotional or sexual abuse or from unsafe sexual practices.

If we are desperately attempting to control our bodies, we may feel ashamed of our “imperfections.” Then how can we believe someone loves us? How can we be honest with a lover when we practise secretive behaviours? How can we demand respect or communicate openly? How can we say what we want sexually, what we prefer not to do sexually and insist on sexual safety?

Treatment for women with an eating disorder will, like treatment for substance abuse, need to examine root causes—if they can be identified—as part of their treatment. The upside is that for women who recover, the prognosis for their sexual lives is positive.

I like to imagine a woman who learns to accept her body, to see it as attractive, and begin to take pleasure in it. I imagine her learning to share her body with another for mutual pleasure and admiration; and I imagine her gradual return to herself along with the desire, and ability, to love and take care of herself.

According to the website Eating Disorders Recovery Today: “in general, interest in, and pleasure from, sexual activity has been shown to decrease at the onset of the disorder and increase during weight restoration. Several explanations for this change in libido are a return to natural (and normal) hormone levels during weight restoration, and the women’s growing comfort with body acceptance and expression during recovery.” It is clear that the effects of an eating disorder are not only psychological and emotional, but physiological as well.

So the good news is, sexual health can be restored. The bad news is, eating disorders and weight preoccupation in general are increasing. We have work to do.